Childhood psoriasis.

Psoriasis is a common dermatosis in children with about one third of all patients having onset of disease in the first or second decade of life. A chronic disfiguring skin disease, such as psoriasis, in childhood is likely to have profound emotional and psychological effects, and hence requires special attention. Psoriasis in children has been reported to differ from that among adults being more frequently pruritic; plaque lesions are relatively thinner, softer, and less scaly; face and flexural involvement is common and guttate type is the characteristic presentation. Whether onset in childhood predicts a more severe form of psoriasis is a matter of controversy, it may cause significant morbidity particularly if it keeps relapsing. Most children have mild form of psoriasis which can be generally treated effectively with topical agents such as emollients, coal tar, corticosteroids, dithranol, calcipotriol etc. according to age and the sites affected. Narrow band UVB is the preferred form of phototherapy in children for moderate to severe disease or in patients not responding to topical therapy alone. Systemic therapies are reserved for more severe and extensive cases that cannot be controlled with topical treatment and/or phototherapy such as severe plaque type, unstable forms like erythrodermic and generalized pustular psoriasis and psoriatic arthritis. There are no controlled trials of systemic therapies in this age group, most experience being with retinoids and methotrexate with favorable results. Cyclosporine can be used as a short-term intermittent crisis management drug. There is an early promising experience with the use of biologics (etanercept and infliximab) in childhood psoriasis. Systemic treatments as well as phototherapy have limited use in children due to cumulative dose effects of drugs, low acceptance, and risk of gonadal toxicity. More evidence-based data is needed about the effectiveness and long-term safety of topical, phototherapy and systemic therapies in children.

Comparative study of calcipotriol (0.005%) ointment and tazarotene (0.05% and 0.1%) gel in the treatment of stable plaque psoriasis.

BACKGROUND: Topical therapies are the first line of treatment for patients with stable plaque psoriasis affecting a limited body surface area. Though in use for more than a decade, we could not find any reports of studies directly comparing calcipotriol and tazarotene. AIM: To evaluate the comparative efficacy and tolerability of calcipotriol and tazarotene in the treatment of stable plaque psoriasis. METHODS: This was a prospective, right-left side intra-individual parallel 8-week study using calcipotriol 0.005% ointment applied twice daily (right side) versus tazarotene (left side) randomized to either 0.05% (group I) or 0.1% gel (group II) once daily in two groups, each of 10 patients. Efficacy was determined by the assessment of target psoriatic lesions under evaluation by using the severity scale (0-3) of erythema, scaling, and infiltration (ESI score). Evaluation was done at baseline (0 week), 4 weeks, and 8 weeks of treatment. At the end of 8 weeks, patients with more than 75% reduction in ESI score were considered to have marked improvement; 51% to 75%, moderate improvement; 26% to 50%, minimal improvement; and less than 25%, non-responders. RESULTS: Seventeen patients (9 in group I, 8 in group II) completed the study. In group I, reduction in ESI score was significantly more at both 4 and 8 weeks on sides treated with calcipotriol, producing moderate-to-marked improvement (P<0.05). In group II, improvement was comparable in lesions treated with either calcipotriol or tazarotene (0.1%) at the end of 4 and 8 weeks. Adverse effects noted were mild--in the form of burning, pruritus, and irritation--and were observed more often in the lesions treated with tazarotene as compared to those in the lesions treated with calcipotriol, but the difference was not statistically significant. However, none of the patients discontinued the therapy because of adverse events. CONCLUSION: Topical calcipotriol 0.005% ointment is more effective than tazarotene 0.05% gel; however, its efficacy is comparable to tazarotene 0.1% gel in the treatment of stable plaque psoriasis.

The future implications and indications of anti-vascular endothelial growth factor therapy in ophthalmic practice.

In the last few years anti-vascular endothelial growth factor (VEGF) therapy has changed the paradigm in the treatment of neovascular age-related macular degeneration (ARMD). Besides, its potential use in the treatment of diabetic retinopathy and other possible proliferative vascular disorders has also shown promise. Clinical trial results have shown tremendous beneficial effect of ranibizumab in ARMD. Off-label use of bevacizumab has also shown similar benefit but long-term and clinical trial results do not exist. Some of the potential questions in the use of anti-VEGF are recurring cost, possible long-term effect on physiological function of VEGF and determination of endpoint of treatment. Overall, the use of anti-VEGF therapy in ocular angiogenesis has proven to be beneficial at least now.

Clostridium difficile toxin assay in psoriatic patients.

Chemotherapy-induced pseudomembranous colitis is most commonly associated with methotrexate and 5-fluorouracil. Methotrexate and mesalazine have also been used for the treatment of psoriasis but the effect of these therapies on the Clostridium difficile carriage in the stool of psoriatic patients has not been studied. Our aim was to detect the presence of C. difficile toxin in patients with psoriasis hospitalized for systemic therapy and in those receiving methotrexate and mesalazine. A total of 58 patients with psoriasis were divided into three groups: group A comprised 30 patients admitted with psoriasis involving >30% body surface area, group B1 comprised 15, psoriatic patients receiving methotrexate (0.3-0.4 mg/kg/week), group B2 included 6 patients receiving mesalazine (50-60 mg/kg/day) while group C comprised of 7 patients (5 on methotrexate, 2 on mesalazine) in whom stool samples were taken twice. Among patients in groups B1 and B2, stool samples were taken after at least 4 weeks of therapy. Detection of C. difficile toxin in stool samples was done using the latex agglutination method. Out of the 58 patients 47 were males and 11 were females. The mean age of the patients was 45+/-2.5 years and the duration of the disease was 3+/-0.9 years. Positive C. difficile toxin was found in a total of 19 patients in all three groups (5 patients in group A, 9 in group B1, 2 in group B2 and 3 in group C). Three patients complained of slight abdominal discomfort and increased frequency of stool, of whom 2 had toxin positive in low titres. The rest of the 17 patients who were positive for C. difficile toxin were asymptomatic. There is a obvious rise in the rate of GIT carriage of C. difficile to a variable degree in patients on methotrexate and mesalazine. However, no clear correlation of the gastrointestinal symptoms with either the presence of toxin or its titre could be established.

Multifocal bullous fixed drug eruption mimicking Stevens-Johnson syndrome.

The overlapping clinical features of fixed drug eruption (FDE), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) make differentiation between them difficult, especially if FDE is multifocal and extensive. We present a case of multifocal bullous FDE mimicking SJS.